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Dot-Mom // From the Wilson Center
Delivering Solutions: Advancing Dialogue to Improve Maternal Health
“Throughout the 2009-2011 Advancing Dialogue on Maternal Health lecture series, we always heard the same good news: we know how to save the lives of women and girls. But more political will is needed,” said Calyn Ostrowksi, program associate for the Wilson Center’s Global Health Initiative on December 15 for the launch of the series’ culminating report, Delivering Solutions: Advancing Dialogue To Improve Maternal Health.MORE
Joining Ostrowski were co-author Margaret Greene, director of GreeneWorks; Luc de Bernis, senior advisor on maternal health at the UN Population Fund; Tim Thomas, interim director for the Maternal Health Task Force; and Chaacha Mwita, director of communications at the African Population and Health Research Center.
One of the few forums dedicated to maternal health, the series brought together senior-level policymakers, academic researchers, members of the media, and NGO workers from the United States and abroad. The series consisted of 21 separate events, with hundreds of experts sharing their experiences and thousands of participants and stakeholders providing their expertise. The final report captures, analyzes, and synthesizes the strategies and recommendations that emerged from the series.
Promoting Social Change
Unlike other health issues, said Green during her presentation on the findings of Delivering Solutions, the field of maternal health requires a holistic and multi-faceted approach; that is, an approach that looks not only at health systems, but also at underlying social factors. The report divides maternal health into three broad categories: social, economic, and cultural factors; health systems factors; and research/data demands.
Looking first at the social, cultural, and economic issues, Greene highlighted the need to improve nutrition and educational opportunities for young women in developing countries. Policymakers must be convinced that investing in women is not just good for women but good for families and children, she said. The participation of male partners and other male family members is also needed to increase access to maternal health services, such as family planning, and promote gender equality. The report pointed to a number of recommendations to promote male engagement:- Target interventions that educate men about danger signs and pregnancy complications.
- Address pressures that many young married men feel to prove their fertility.
- Inform men about sexual rights and how they relate to the health and wellbeing of their partners.
Health systems and medical resources play an equally pivotal role in reducing maternal mortality as social factors. The report highlights several key areas for strengthening the health system including the expansion of healthcare workers, health finance schemes, technology, and commodity distribution.
One key recommendation is to integrate reproductive health and maternal health supply chains. Four key medicines, oxytocin misoprostol, magnesium sulfate, and manual vacuum aspirators, target the three leading causes of maternal mortality (post-partum hemorrhage, obstructed labor, and unsafe abortion). Efforts to improve the distribution of these commodities should be more widely dispersed in developing countries and supported by community-based interventions. Women in urban slums, for example, face unique challenges that are not being adequately addressed.
Additionally, new technologies should be more creatively and effectively used, in particular the use of mobile phones in rural communities.
Many of the policy recommendations offered by the report, as Greene pointed out, are low-cost and highly effective. Yet three significant challenges remain for the field in general:- Six countries – Afghanistan, Democratic Republic of Congo, Ethiopia, India, Nigeria, and Pakistan – account for over half of the maternal deaths worldwide. The unique problems of each of these countries must be addressed and solved.
- Integration of maternal health with existing health services along with an over-reliance on community health workers can overburden weak infrastructure.
- Unnecessary cesarean births are on the rise as more women deliver in private sector facilities. These births cost 2 to 18 times as much as vaginal births and create unnecessary risks for mothers.
Chaacha Mwita of the African Population and Health Research Center (APHRC), located in Nairobi has seen firsthand the result of an overburdened and inadequate maternal health system in both his personal and professional life. Mwita endorsed the findings of the series report, emphasizing in particular the focus on transportation systems, male involvement, stakeholder dialogue, and education.
Mwita said that collaboration at all levels is the key to improving maternal health. Policymakers must communicate with researchers, who, in turn, must communicate with doctors, nurses, and hospital administrators in the field. The collaborative in-country dialogue series between the Wilson Center and APHRC, he believes, was a highly useful and easily replicable way of encouraging dialogue among relevant stakeholders in the field.
The Big Picture
”Our hope is that we’ve been able to seed discussions,” said Tim Thomas of the Maternal Health Task Force, one of the co-sponsors of the maternal health series. “We hope those seeds will take root and flourish.” Luc de Bernis, senior maternal health advisor of UNFPA, echoed Thomas’ sentiments, emphasizing the need for continued dialogue.
While maternal health has drawn increased international attention, creating political agreement among policymakers is a complex and often difficult process. There has been marked, though uneven, progress in improving maternal health across the globe, but more must be done. The Delivering Solutions report provides a state of the field assessment as well recommendations for existing, easy-to-implement solutions.
Event Resources:Topics: Africa, Dot-Mom, From the Wilson Center, funding, gender, global health, Kenya, maternal health, video -
On the Beat
People and Wildlife Compete in East Africa’s Albertine Rift
MOREThe original version of this article, by Robert Draper, appeared on National Geographic.
The mwami remembers when he was a king of sorts. His judgment was sovereign, his power unassailable. Since 1954 he, like his father and grandfather before him, has been the head of the Bashali chiefdom in the Masisi District, an undulating pastoral region in eastern Democratic Republic of the Congo (DRC). Though his name is Sylvestre Bashali Mokoto, the other chiefs address him as simply doyen – seniormost. For much of his adult life, the mwami received newcomers to his district. They brought him livestock or other gifts. He in turn parceled out land as he saw fit.
Today the chief sits on a dirty couch in a squalid hovel in Goma, a Congolese city several hours south of Masisi. His domain is now the epicenter of a humanitarian crisis that has lasted for more than a decade yet has largely eluded the world’s attention. Eastern Congo has been overtaken by thousands of Tutsi and Hutu and Hunde fighting over what they claim is their lawful property, by militias aiming to acquire land by force, by cattlemen searching for less cluttered pastures, by hordes of refugees from all over this fertile and dangerously overpopulated region of East Africa seeking somewhere, anywhere, to eke out a living. Some years ago a member of a rebel army seized the mwami’s 200-acre estate, forcing him, humiliated and fearing for his safety, to retreat to this shack in Goma.
The city is a hornet’s nest. As recently as two decades ago Goma’s population was perhaps 50,000. Now it is at least 20 times that number. Armed males in uniform stalk its raggedy, unlit streets with no one to answer to. Streaming out of the outlying forests and into the city market is a 24/7 procession of people ferrying immense sacks of charcoal on bicycles or wooden, scooter-like chukudus. North of the city limits seethes Nyiragongo volcano, which last erupted in 2002, when its lava roared through town and wiped out Goma’s commercial district. At the city’s southern edge lies the silver cauldron of Lake Kivu – so choked with carbon dioxide and methane that some scientists predict a gas eruption in the lake could one day kill everyone in and around Goma.
The mwami, like so many far less privileged people, has run out of options. His stare is one of regal aloofness. Yet despite his cuff links and trimmed gray beard, he is not a chief here in Goma. He is only Sylvestre Mokoto, a man swept into the hornet’s nest, with no land left for him to parcel out. As his guest, a journalist from the West, I have brought no gifts, only demeaning questions. “Yes, of course my power has been affected greatly,” the mwami snaps at me. “When others back up their claims with guns, there is nothing I can do.”
Continue reading on National Geographic.
Photo Credit: “Aerial View of Goma,” courtesy of UN Photo/Marie Frechon.Topics: Africa, agriculture, Burundi, conservation, development, DRC, environment, environmental security, forests, land, On the Beat, population, Rwanda, security, Uganda -
The Walk to Water in Conflict-Affected Areas
May 18, 2011 // By Wilson Center StaffMOREConstituting a majority of the world’s poor and at the same time bearing responsibility for half the world’s food production and most family health and nutrition needs, women and girls regularly bear the burden of procuring water for multiple household and agricultural uses. When water is not readily accessible, they become a highly vulnerable group. Where access to water is limited, the walk to water is too often accompanied by the threat of attack and violence.
Topics: conflict, food security, gender, humanitarian, natural resources, risk and resilience, USAID, water -
Eye On
Mapping the Hot Spots of the 2010/11 Food Crisis
MOREIf you’ve taken a trip to the supermarket lately or scanned the headlines you may have noticed something: Food prices are on the rise. Worldwide, food prices are on track to reach their highest point since their peak in 2008. Using data from the Food and Agriculture Organization (FAO), the International Food Policy Research Institute (IFPRI), and the World Bank, the Environmental Working Group (EWG) and ActionAid have collaborated to create an interactive world map called, “Hot Spots in the Emerging Global Food Crisis.”
The focus of the map is to highlight the 52 most at-risk countries where increases in staple food prices could tip the scales of stability. There are three variants of the map to choose from: countries at risk which depend on imported cereals, countries where prices are already increasing (featured above), and countries with vulnerable economies and high rates of hunger.Food prices have become a hot topic of conversation lately for their alleged role in the instability that is rocking the Middle East/North Africa region. But the Middle East is not the only area affected: Besides in Algeria, Tunisia, Morocco, Jordan, and Egypt, food-related riots and protests have also broken out in Mozambique, Bolivia, and India. As the map’s accompanying text puts it, these food riots “feed deeper discontent about economic inequalities and hunger and help give rise to revolutions that can topple governments, as in Tunisia and Egypt.”
Scrolling over a country reveals more information, like, for example, the specific percentage increases in the price of wheat or rice over the past year (wheat prices have risen 15.9 percent in China vs. 54 percent in Kyrgyzstan) or the amounts of corn, soybean, and wheat annually imported and exported (Afghanistan exported 908 million metric tons of wheat in 2010 while Egypt imported 4,978).
Users can also click on vulnerable countries to see how many people are malnourished and their per capita income per day. In the Democratic Republic of the Congo, for example, an estimated 42 million people were undernourished between 2005 and 2007, and the average person lives on $0.28 per day. According to EWG and ActionAid, the total number of people living in extreme poverty rose by 25 million in 2008 during the last global food crisis. Since June 2010, the start of the current upward trend in prices, the World Bank estimates that 44 million people have fallen into extreme poverty.
One recommendation from EWG and ActionAid for developed countries and the United States in particular: Stop looking to biofuels as an energy option. In their view, “spending scarce taxpayer dollars to shift crops from food to biofuels at the expense of hungry people and already stressed resources like soil, water, and air is unsustainable.”
Image Credit: Map courtesy of the Environmental Working Group and ActionAid, and Food Price Index and Food Commodity Indices, extracted from Global Food Price Monitor, January 2011, courtesy of the Food and Agriculture Organization.
Sources: ActionAid International, BBC News, CNN, the Environmental Working Group, The European Union Times, Time, Voice of America, World Bank. -
Watch: Richard Cincotta on Political Demography and Unrest in the Middle East
March 9, 2011 // By Schuyler Null“Countries that have a high proportion of young people are typically more prone to political violence,” said demographer-in-residence at the Stimson Center, Richard Cincotta, in this interview with ECSP. “That is, not necessarily international war [but] internal conflict, which may take different forms,” including civil and ethnic strife, domestic terrorism, and violent political demonstrations.MORE
The role of unemployed and angry youths in the recent unrest that has swept the Middle East has received a great deal of coverage, but though the region in general is very young, some countries are more so than others.
Tunisia (median age of 29) is actually well into its demographic transition, where fertility declines towards replacement level. “Fertility – the number of children women have in their lifetime – is now lower than it is in the United States,” said Cincotta. As a result, Tunisia’s prospects for achieving a stable, liberal democracy – based on the historical relationship between age structure and political freedoms (see Cincotta’s full post on Tunisia and the two follow-ups for a more complete treatment of that relationship) – are about even.
In contrast, Egypt’s age structure remains young (median age of 24) and Yemen’s (median age of 17) is extremely young. “Those difference are very stark,” said Cincotta, and they play out in the risk of political violence: Tunisia is less likely to experience continuing political violence; Egypt, more so; and Yemen, even more likely.
The relationships between age structure and political violence and the emergence of democratic institutions can be useful in other conflict-prone regions as well. “Afghanistan, Pakistan, Iraq, the Palestinian Authority, most of the central band of sub-Saharan Africa – from Nigeria to the Congo, to Kenya and Ethiopia – we know that these countries are volatile, we’re not always sure why,” said Cincotta. But “age structure gives you a clue, because it tells you something about a lot of barriers that are important to development.”
Sources: UN Population Division.Topics: Afghanistan, Africa, conflict, democracy and governance, demography, development, DRC, Egypt, Ethiopia, Iraq, Kenya, Middle East, Pakistan, Tunisia, video, youth -
Mapping Demographics in WWF Priority Conservation Areas
February 25, 2011 // By Hannah MarquseeMORE“The developing world is urbanizing at a dizzying pace,” yet rural populations living in developing countries are also rapidly increasing, threatening many of the planet’s most biodiverse regions, says a new study, Mapping Population onto Priority Conservation Areas, by David López-Carr, Matthew Erdman, and Alex Zvoleff.
Using comprehensive data from the USAID-sponsored Demographic Health Surveys (DHS), the researchers analyzed population, mortality, and fertility indicators for 10 of the 19 priority places for conservation identified by the World Wildlife Foundation (WWF). These biological hotspots represent parts of 25 countries throughout South Asia, sub-Saharan Africa, and South America, including the Democratic Republic of the Congo, Colombia, Guatemala, Indonesia, Kenya, Nepal, Madagascar, and Thailand.
Urban vs. Rural
The findings confirmed the researchers’ hypothesis that rural areas within WWF priority regions are at a lower state of demographic transition than their urban counterparts, meaning they have higher fertility and infant mortality rates and a younger age structure due to poor access to primary health care, including family planning. Furthermore, women in these regions desire more children than those in urban, non-priority areas, but experience a greater difference between ideal and actual number of children.
For many of the indicators, the differences between urban and rural, and priority and non-priority, regions of the developing world are striking. In urban Asia, the mean predicted population doubling time is 86.1 years; in rural Africa it is only 24.6 years. Urban Asia and South America also have total fertility rates of 1.8 children per woman, while rural Africa’s is 5.2. Infant mortality also ranged from a low of 20 deaths per every 1,000 births in some developing urban areas, to over 100 in rural parts of Coastal East Africa. In the developed world it is less than 10.
There is also consistently less desire among women in priority areas to limit their childbearing. Worldwide, 49.4 percent of women living within priority areas want to limit childbearing, compared to 56.2 percent outside priority areas.
Rural areas in all regions had the highest unmet need for family planning, with the exception of the Congo Basin, where high infant mortality has persisted and dampened women’s desire to limit childbearing. “If much needed health services were provided in the Congo Basin, along with family planning services, child survival rates would increase, and couples would be more inclined to limit overall births,” the study says.
Lower demand for family planning in priority areas is consistent with Caldwell’s theory of intergenerational wealth flows, the paper noted, which explains how in rural agricultural societies, children are economic assets who move wealth to their parents. As countries develop and people gain access to education, healthcare and female empowerment, wealth flows reverse and children become financial burdens. This transition decreases fertility and increases demand for family planning.
Setting Priorities
As WWF plans to scale up its population, health and environment (PHE) programs, this study will help to prioritize places within priority areas that are most in need of PHE intervention and “are most likely to help alleviate negative environmental and social impacts of rapid population growth.” The results of this study show that many areas are ripe for such intervention:Nearly a quarter of households in Coastal East Africa and the Mesoamerican Reef wish to have access to contraception yet their desire remains unfulfilled. Similarly, households within priority places in Coastal East Africa, the Mesoamerican Reef, Amazon and the Guianas, and the Eastern Himalayas wish to have nearly one child fewer than they currently have.
The findings of this study have already informed the planning of several of WWF’s projects in Madagascar and Namibia.
The limited availability and detail of the DHS data was the primary limitation of the study, the researchers noted. The 25 countries examined did not fully cover all WWF’s priority areas – 17 other countries within the priority areas lacked sufficiently comprehensive data for the study. Furthermore, the district or municipality was the smallest unit of analysis possible with DHS data, making it difficult to exactly pinpoint priority communities.
“Geography matters,” write the authors. “Only with further refined data accompanied by qualitative on-the-ground field research can we credibly answer remaining questions.”
Image Credit:“Family Planning: Unmet Need for Family Planning Services” and “Mortality Rate: Child Mortality Rate (Under Age 5)” courtesy of World Wildlife Fund.
Sources: Population Council, World Wildlife Fund. -
Beat on the Ground
Improving Health and Preserving Ecosystems in the Democratic Republic of Congo
MOREThis PHE Champion profile was produced by the BALANCED Project.
In the remote forests of the Democratic Republic of Congo (DRC), Albert Lotana Lokasola is helping improve livelihoods by bringing much-needed health services to the communities living in and around the Kokolopori Bonobo Reserve. Officially recognized by the DRC government in May 2009, the reserve is a high biodiversity wilderness area covering an area about the size of Rhode Island (4,785 square kilometers).
Located 300 miles southwest of Kisangani, the reserve contains bonobos, a rare and highly endangered great ape species that is as closely related to humans as chimpanzees. In addition, the reserve is highly valued for its biodiversity, including several other flagship species such as leopards, elephants, Congo peafowl, Tshuapa red colobus, and Salonga monkeys.
Lokasola founded a nationally recognized organization called Vie Sauvage, or “Wild Life” in English. He serves as the president of the organization and works with international organizations to foster conservation and rural development in an integrated, holistic approach. As a native of Kokolopori, he believes that “the forest, men, and wildlife live together and should be protected together.”
In partnership with local residents and supported by the Bonobo Conservation Initiative, Lokasola and Vie Sauvage established the first medical clinic in the area in 2006. They garnered support for a doctor, nurses, and supplies from the Indigo Foundation in Australia and the Kokolopori-Falls Church Sister City Partnership.
Before the clinic was founded, community members had to walk or bicycle more than 50 miles to get to the nearest hospital in the territorial capital of Djolu. Now the Kokolopori clinic serves the 8,000 people who live in 30 villages along a 40-mile road in the reserve. One of the clinic’s goals is to help improve women’s health by training and equipping midwives and by providing access to other health services. Malaria and poor nutrition contribute to high maternal and child mortality, and women in Kokolopori do not yet have access to reproductive health services such as family planning.
Vie Sauvage articulates integrated health and conservation messages through their community education projects. They are also working with the community to prevent malnutrition by planting fruit trees in agroforestry fields to produce supplemental food supplies. At the same time, these trees will create corridors for wildlife movement and protect the genetic flow. They also create a sound micro-climate for people, sequester carbon dioxide, and filter the air. Through these efforts, Vie Sauvage and the people of Kokolopori are demonstrating the critical links between human well-being and conservation.
Vie Sauvage has garnered resources and participation from diverse partners (like the Kokolopori-Falls Church Sister City Partnership and the Indigo Foundation, mentioned above) which work together to support the clinic and fund medical staff salaries, training, supplies and equipment, and infrastructure improvements.
According to Lokasola, Vie Sauvage and partners are currently exploring potential partnership opportunities to integrate family planning and reproductive health into existing activities. His hope is that by providing these much-needed services, the community will be healthier and critical ecosystems will be sustainably preserved.
This PHE Champion profile was produced by the BALANCED Project. A PDF version can be downloaded from the PHE Toolkit. PHE Champion profiles highlight people working on the ground to improve health and conservation in areas where biodiversity is critically endangered.
Photo Credit: Building along the road in Kokolopuri village serves as a messsage drum for sending messages from one village to the next, courtesy of Ingrid Schulze and the BALANCED Project. -
From the Wilson Center
Gender-Based Violence in the DRC
MOREIn the Democratic Republic of the Congo (DRC), “armed conflict has resulted in mass displacement and widespread sexual violence; the problem is that it hasn’t always been quantified,” said Dr. Lynn Lawry, senior health stability and humanitarian assistance specialist at the U.S. Department of Defense. Presenting findings from the first cross-sectional, randomized cluster study on gender-based violence in the DRC, Lawry was joined at the Wilson Center by Heidi Lehmann, director of the Gender-based Violence Unit at the International Rescue Committee, and Dr. Nancy Glass, associate professor at the Johns Hopkins School of Nursing and associate director at the Johns Hopkins Center for Global Health. “We found that sexual violence in these areas is conflict-related, prevalent, systematic, and widespread,” said Lawry. [Video Below]
Study Finds “Female Perpetrators”
The first of its kind in the region, the population-based, quantitative study covers three districts in the DRC and a total of 5.2 million adults. It comprehensively assesses gender-based violence, including its prevalence, circumstances, perpetrators, and physical and mental health impacts.
Overall, the study found that 2.1 million women and 1.3 million men in the region had suffered sexual violence. Nearly three-quarters of all sexual violence reported was a direct result of conflict. In the study region, 20 percent of the population fought in conflicts, and 48 percent of these combatants were female.
Further, 39 percent of female survivors and 15 percent of male survivors reported female perpetrators. “These findings challenge the paradigm of male perpetrator and female victim,” said Lawry. “Policymakers and donors should adjust societal paradigms of sexual and gender-based violence and also direct attention to female perpetrators and male survivors.” Survivors of sexual violence in conflict, both male and female, are more at risk of later becoming perpetrators, particularly if unrecognized and untreated. To “break the cycle of violence,” prevention and response programs should address the needs of survivors and combatant perpetrators of both genders.
“Community-related violence is a general crime; conflict-related violence is a war crime,” Lawry said. While many efforts have focused on the Congolese military, she called for the DRC government and the International Criminal Court to also investigate and prosecute members of rebel groups, who were found to be the main perpetrators of sexual violence and other human rights abuses in this study.
Prevention: The Best Response
“Meeting the immediate consequences of violence is not enough,” said Lehmann. To effectively address gender-based violence, programs must provide medical and social services, promote social empowerment, respond to emergencies, and take part in advocacy and coordination efforts.
In the DRC, programs supported by the International Rescue Committee serve approximately 350 to 400 survivors per month, 75 percent of whom report that the perpetrators are members of armed groups.
Scaling up is a major challenge. “Providing essential services alone require enormous investment, and there is no common understanding of comprehensive programming,” said Lehmann. “We recognize that a program alone cannot solve all of these problems, especially in the DRC.”
“Good response is about prevention,” concluded Lehmann. She recommended supporting robust, long-term programming; integrating gender-based violence prevention efforts into other sectors; and investing in partnerships. “We are not going to end the violence unless Congolese women and girls are part of the conversation.”
Pigs for Peace: A Holistic Approach
Health care, economic development, and social programs should be integrated “to provide a holistic and comprehensive approach” to the problem of gender-based violence, said Glass. “Rape destabilizes families and communities,” she said.
Survivors rarely get immediate treatment for their injuries and trauma, or the risk of HIV, STIs, and infertility. “Many rural primary health centers and hospitals have been looted of medicines and materials by rebels and soldiers,” said Glass. Conflict in the DRC has also caused health care professionals to leave unstable rural areas, and poor roads and limited transportation make it unsafe and expensive to seek care.
To rebuild families and communities, “women and men need to regain their economic resources to provide for the future of their family and community,” said Glass. Pigs for Peace, for example, has supplied more than 100 women — many of them rape survivors — and their families with pigs to set them on the path to recovery through psychological, social, and economic empowerment. This program aims not only to supplement household income, but to reduce the stigma of rape as survivors become productive parts of their families and communities.
Photo Credit: “Congo kivu,” courtesy of flickr user andré thiel.
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